Background: The Veterans Health Administration has a long history of providing maintenance dialysis treatment for Veterans with end-stage renal disease (ESRD) in the community under the VA Fee Basis program. Starting Fiscal Year 2015, access to specialized nephrology care in the community became available to the much larger population of Veterans with advanced kidney disease not yet on dialysis under the Veterans Choice Program (VCP) and is expected to continue under a consolidated Community Care program. Like their counterparts on dialysis, Veterans with advanced kidney disease not on dialysis are a high-cost high-needs population for whom access to care, continuity of care and coordination of care are all vitally important in optimizing quality and outcomes. All three metrics are important in building strong relationships between patients and providers, and supporting the kind of iterative cycle of evaluation and re-evaluation and care coordination needed to properly care for these patients Objective: We will use mixed methods to study the impact of the VA?s evolving community care policy on outcomes and costs for Veterans with advanced kidney disease and identify opportunities for program improvement. Because many of the outcomes and care processes relevant to this population are sensitive to continuity and coordination of care, we hypothesize that receipt of VA-financed nephrology care in the community will negatively impact a range of clinical outcomes and care processes relevant to this population and will be more costly than nephrology care provided within the VA. We anticipate that for some groups, the potential harms of care fragmentation and discontinuity may be outweighed by the benefits of more timely receipt of needed care in the community. Because some VA medical centers may be more effective in coordinating care with community providers to mitigate the effects of care fragmentation, we hypothesize that there will be heterogeneity in the effect of VA-financed community care within the population and across VA medical centers that could be informative in improving the process of community referral for this population. Methods: We will use national VA administrative and clinical data to track the impact of VA-financed community care on clinical outcomes, care processes and costs to the VA system among Veterans with advanced kidney disease using an instrumental variable approach (Aim 1). To identify opportunities for improving the value of community referral for this population, we will elicit the perspectives and experiences of Veterans with advanced kidney disease eligible for, or receiving VA-financed community care and their VA and community care providers (Aim 2). Impact: This proposal will directly address three VA HSR&D priority areas (Health Care Systems Change, Healthcare Access and Patient-centered Care, Care Management, and Health Promotion). The work proposed here is extraordinarily timely and policy-relevant given that the VA MISSION Act of 2018 recently passed both the House and the Senate with strong bipartisan support. We anticipate that our work to measure the impact of VA-financed community nephrology care on Veterans with advanced kidney disease will help to identify opportunities for more effective use of agency resources to optimize access, continuity and coordination of care for a high-cost high-needs segment of the Veteran population. To ensure that our work is poised to shape evolving VA policy around provision of community care, the investigators are partnering with the VHA National Program for Kidney Disease and the Office of Community Care.